Anti-VEGF injections vs laser for premature infants: Does neurodevelopment differ?

Clinical takeaway: Do not select anti-VEGF therapy or laser photocoagulation for retinopathy of prematurity (ROP) solely on the assumption that one is safer for neurodevelopment. Individualize treatment and continue appropriate developmental surveillance, particularly after intravitreal bevacizumab.

An American Academy of Ophthalmology technology assessment found no clear difference in neurodevelopmental outcomes between premature infants receiving intravitreal anti–vascular endothelial growth factor (VEGF) therapy and those undergoing laser photocoagulation as primary treatment for retinopathy of prematurity (ROP).

The review included 26 studies conducted across 39 countries: four reports from three randomized controlled trials and 22 comparative cohort studies. Twenty studies (77%), including all randomized trials, detected no statistically significant difference between treatment groups. The evidence was rated level II or III; no level I evidence was available.

Findings involving specific agents warrant caution. Four observational studies reported worse neurodevelopmental outcomes after intravitreal bevacizumab, whereas two studies found worse outcomes after laser. These conflicting results may reflect treatment-selection bias because infants receiving anti-VEGF therapy often had more severe ROP or greater medical complexity. The evidence was insufficient to establish that bevacizumab caused poorer outcomes or to distinguish reliably among bevacizumab, ranibizumab, and aflibercept.

Long-term evidence remains particularly limited. Most assessments occurred before 24 months of age, and only five studies measured IQ after age 4 years. None of those studies found a significant IQ difference between anti-VEGF therapy (bevacizumab in four studies and ranibizumab in one) and laser treatment.

The authors concluded that the available evidence showed “no evidence that neurodevelopmental outcomes differed” between the two approaches. However, no included study was powered specifically to detect small developmental differences. Thus, absence of statistical significance should not be interpreted as proof of equivalent safety.

The assessment supports shared, individualized decision-making based on ocular disease characteristics, treatment benefits and risks, infant comorbidities, and the need for ophthalmic and neurodevelopmental follow-up.

Source: Prakalapakorn G, et al. (2026 Jul) Ophthalmology. Anti-VEGF versus Laser Photocoagulation Surgery for Primary Treatment of Retinopathy of Prematurity: Neurodevelopmental Outcomes (Ophthalmic Technology Assessment)